the nightmare in cath lab: early identification and emergent correct treatment
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The Nightmare in Cath Lab: Early Identification and Emergent Correct Treatment. Yuejin Yang MD, PhD, FACC, FESC Cardiovascular Institute and Fu-Wai Hopital, CAMS & PUMC. The 11th Nanjing Course on Cardiac Revascularization & ACS, in conjunction with CAP-CCBC, Nanjing, Sept. 13, 2013. - PowerPoint PPT PresentationTRANSCRIPT
The Nightmare in Cath Lab: The Nightmare in Cath Lab: Early Identification and Emergent CEarly Identification and Emergent C
orrect Treatment orrect Treatment
Yuejin Yang MD, PhD, FACC, FESCYuejin Yang MD, PhD, FACC, FESC
Cardiovascular Institute and Fu-WaiCardiovascular Institute and Fu-Wai
Hopital, CAMS & PUMCHopital, CAMS & PUMC
The 11th Nanjing Course on Cardiac Revascularization & ACS, in conjunction with CAP-CCBC, Nanjing, Sept. 13, 2013
The 11th Nanjing Course on Cardiac Revascularization & ACS, in conjunction with CAP-CCBC, Nanjing, Sept. 13, 2013
Numbers of PCI in Each Year @ Fu Wai
415 618 9211386 1605
19672555
32823821
47785148
6599
8050
10649
3 3 13 186 374706
12472018
2659
38404326
5623
7229
9673
0
2000
4000
6000
8000
10000
12000
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Total PCI Radial
2011: PCI case No: 10649, Radial 90.8%2011: PCI case No: 10649, Radial 90.8% (( 9673/10649)9673/10649)
TRI from <1% in 1998 to >90% in 2011 with the very low mortality rate of just 0.05% in elective PCI
TRI from <1% in 1998 to >90% in 2011 with the very low mortality rate of just 0.05% in elective PCI
The Impact of PCI on CHD
Effective in:– Interventional revascularization
– Cure the patients with CHD
Safety problems:– Severe complications
Hurt the patients
Even leading to death of the patients
If identification late and treatment
improperly or correctively
– Or nightmare in the Cath Lab
Nightmares in Cath Lab ?
Severe PCI complications
Resulting in severe consequences
Even leading to:
– death
– MI
– Emergency CABG
Category of PCI ComplicationsCoronary
Puncture site
Others
Stent related (BMS, DES)
TRI related
Medication related:– Antiplatelet and anticoagulation– Contrast media
Hypersensitivity (anaphylactic shock)
AKI
Coronary Complications
Coronary injury leading to:
Severe dissection
Acute closure
Rupture
Perforation
Thrombosis
Thrombotic embolism
Access Site Complications
Bleeding
Big hematoma
Post-peritoneal hematoma
A-V fistula
Vessel injury (dissection)
Thrombosis
Thrombo-embolism
Infection
Other Complications
ComorbiditiesSystemic thrombo-embolismsMicrovascular embolisms
( thrombosis and air)StrokeBrain hemorrhageGI bleedingBleeding on other organsVagal reflex and hypotensionHemodynamic instability
Stent Related Complications
Stent thrombosisAcute (<24 hrs)
Subacute (1-30 ds)
Late (1-12 ms)
Very late (>1 yr)
Definite
Probable
Possible
Stent dislodge
Stent dystroy
TRI Related Complications
Radial artery closureVessel injury by wire and hematoma along with the route
Forearm hematoma and osteo-compartment syndromeNeck hematomaMediastinum hemotomaChest hemotoma or pleural bleedingStroke
Aortic dissection
Medication Related Complications
Dual antiplatelet and antithrombin therapyBleeding ( brain, GI, fundus, gum, et al)
Hemotoma
HIT due to heparin
Plateletcyclopedia due to 2b/3a inhibitor at al
WBC decrease
Hypersensitivity
Contrast media CKD
Allergy even allergic shock
Clinical Nightmares in Cath Lab
CV collapse
Big coronary (including sidebranch) acute closure
Coronary rupture
Severe no-reflow phenomenon
Cardiac tapenade
Severe allergic shock
Stent thrombosis
Brain hemorrhage
stroke
Case 1: CV Collapse after CAA in Pts with STEMI (IPW)
Mr. Zhang Zhengang, M 66 yrs, 810865
STEMI (IPW) for 4 hrs, 2012-6-13
CV collapse after LCA A
Bp continually declined before RCA A
Continuous CPR, IABP, Intubation preparation
IABP pulled out during CPR
Left femoral approach to RCA A
TIMI flow II with 95% stenosis
Case 1: CV Collapse after CAA in Pts with STEMI (IPW)
TIMI flow back to III after 1st aspiration
Residual stenosis 90%
After 2nd aspiration, residual stenosis 80%
No PTCA, No Stent
CCU stay for 10 days
CABG suggested, but 1-2 Mons later needed
Pts discharged on his own demand
Baseline LCA A
LAD & LCX CTO Poor local collateral circulation
CPR and RCA A
Bp declined before RCAA LFA RCAA under CPR
Final Results• After 2nd aspiration,
TIMI flow III• RCA to LAD collateral
circulation• Residual stenosis 80%• IABP via LFA • Pts calmed,
hemodynamics stable• Sent to CCU
Case 2: Severe Complication – LM dissection leading to acute closure
Mr. Song Chen Wu, M 40 yrs, 841948
2013-2-26
XB-LAD Guiding
LM dissected and acute closure
Baseline CAA
Guiding engaged uncoaxially LM & LAD dissected severely
LAD closure
LAD acute closure & IABP support, Wiring
Guiding changed to Judkins L3.5
Rescue Successful
Wiring successful & ballooning TIMI flow III
Stenting
Final Results
Case 3 RCA Rupture after Post-stent Kissing
Mr. Wang Yu min, M 54 yrs, 819648
2012-9-19
Admitted due to ACS
Baseline CAA
LAD 80%, Dia 80%, distal LCX 80%
Distal RCA & Bifurcation 90%
PTCA and Stenting
After PTCA After Stenting ( 2.75 × 24mm )
Kissing Ballooning
1st Kissing OK 2nd Kissing with high pressure of 12atm
RCA Rupture
RCA Rupture Balloon occlusion, pericardial centesis, cardiac surgeon consulted
Covered Stent
Covered stent Almost sealed
Final Results ?
40 Minutes Later
Massive clot showed in pericardium & stent leakage at distal vessel
Obvious contract media stay in pericardial cavity
Re-sealed
Another covered stent, JR guiding very deep seating to seal the leakage
Covered stent deployed & leakage sealed with the price of PDA acute closure
Final Results
No sign of pericardial effusion
Pericardial Cine Check
No sign of pericardial effusion
Case 4: LAD&Dia two stent complicated with ST
Mr. Ni Xiang ren, M 45, 819127
2012-8-22
Admitted due to ACS
Baseline CAA
LAD 90%, big Dia 90%, LCX 90% Distal RCA 100% with collateral circulation from LAD
Two Stent Strategy
Rewiring & Reballooning Kissing ballooning
Final Results
OK OK
3 Hrs Later, Chest Pain with ST Elevation
Stent total occlusion due to AST Ballooning
Final Results
TIMI Flow OK, LCX 100% Flow sluggish without emptying, CV Collapse happened, CPR
Case 5: Acute Closure of Big RCA
Mr. Shang Feng yi, M 56 yrs, 838552
2013-1-13
Big RCA very tortuous
Acute closure due to wire injury
Baseline CAA
LAD & LCX OK Big RCA very tortuous with tight lesion
RCA Closure and Rescue
RCA acute closure due to BMW injury
IABPPilot 50 wiring & ballooning
Stenting
Big RCA opened Stenting
Final Results
OK, No distal dissection RCA TIMI flow III
Case 6: RCA Stenting Complicating with Side Branches Acute Closure
Mrs. Cao Wen hua, F 64 yrs, 782315
2012-1-10
CABG for 5 yrs
LAD & LCX 100%
RCA In-stent stenosis & occlusion with big side branches
Baseline CAA
LAD & LCX 100% RCA In-Stent 100% involving two PDA branches
RCA PCI
Ballooning without side branches wire protection
Two big branches acute closure
RCA PCI
Hemodynamic unstableIABP & Temporary Pacemaker
Two side branches TIMI flow I+
One weeks later, Pts died of SCD
Case 7: High risk pts without hemodynamic support
Mrs. Zhang Xiu zhen, F 80 yrs, 713486
2010-2-8
Primary PCI for STEMI
High risk Pts without hemodynamic support
Baseline CAA
LAD 100% RCA 70%
Ballooning
Pre-stent ballooning After ballooning, TIMI flow I& CV collapse happened
IABP & Reballooning
IABP & Reballooning TIMI flow remained I
Take Home Messages
Always keep in mind:
– There are some possibilities of complication
when we do every PCI cases
– Early identification and emergent correct
management can avoid the nightmare in the
Cath. Lab.
WelcomeWelcome Attend China Heart Conference (IHF2014)Attend China Heart Conference (IHF2014) ::
6th6th international TR Coronary Therapeutics (T international TR Coronary Therapeutics (TRCT)RCT)
Chaired byChaired byYue-Jin Yang MD. PhD. FACCYue-Jin Yang MD. PhD. FACC
Co-Chaired byCo-Chaired byDr. SaitoDr. Saito
Dr. kiemeneijiDr. kiemeneijiCNCC, CNCC, 2014/08/08-11, Beijing, China2014/08/08-11, Beijing, China
Thank You for Your Thank You for Your Attention !Attention !